International Medical Graduates

This page is dedicated to those GP trainees who are training in the UK but who have graduated in medicine at a university elsewhere (like Africa, India, Spain, Romania and so on) and their GP Trainers. International Medical Graduates are often referred to as IMGs.  Personally, I feel a little uncomfortable with labelling a group of people in this way because it encourages stereotypes rather than embracing individuality and diversity.  This is made worse when the word is often used in association with negative circumstances.    However, if you are a trainee reading this, what I can safely say is that medical educators who use this word are usually using it to help identify a group of people who they genuinely want to help.

If you graduated outside the UK, I hope this web page will help bridge some of the gaps – there are quite a number of tips on this page to help you with the MRCGP and GP training in general. If you have any further comments or recommendations, please drop me a line at rameshmehay@googlemail.com

The problem with most GP training schemes in the UK (and the accompanying formal assessment procedures) is that most are based on a ‘formula’ which is really only suited to those who graduated in the UK. For instance, CSA/ RCA courses tend to assume that you have good enough knowledge of ‘British culture, language and linguistics’. We know that IMGs struggle with specific components of the MRCGP exams because of this.  

Although many IMGs underperform, the fact remains – they are highly intelligent people.  Please remember that less than 1% of the world’s population have a medical degree!   Compared to British born-and-bred graduates, IMGs have a very difficult intellectual task to do. In addition to dealing with medical issues, they have to do  a number of things simultaneously that the rest of us take for granted – like translating between two languages, trying to understand non-verbal and verbal nuances, grasping colloquial remarks, and doing that extra thing to make patients feel that they’re being understood and respected.   How would we fair with these other tasks if we were in another country?

In terms of MRCGP, the main difficulty IMGs face is with CSA/ RCA and the COT part of Work Place Based Assessment. Unfortunately, there is a much higher failure rate amongst IMGs doing the CSA than those who graduated from the UK.   We think the problem is that IMGs are being taught consultation skills but are not being taught how to apply them.     The other problem is that most IMGs are relatively socially and physically isolated compared to those born in this country.  This is made worse if they belong to a scheme on the coast like Scarborough or Cornwall.   We need to somehow tackle this too if we are to improve their social, linguistic and cultural capital.  Interestingly, female IMGs find it easier to adapt to the professional culture in the UK than men. This may be because women in other cultures may not have the same status and expectations as their male counterparts and are therefore more adaptable to the ‘ partnership’ approach that is expected UK doctors.

Some trainees attend CSA courses and get told (in their feedback) that they need to be ‘more British’. Personally, I think it’s an awful phrase because

1. It is vague and therefore can mean different things to different people.  For example, is spending two weeks in a European mass tourist holiday destination, getting sunburnt, drinking too much, slurring unintelligible football chants and taking all sorts of risks with one’s sexual health the essence of being British? Or is it tut tutting at such behaviour through the pages of a popular newspaper? (Hopefully, you’ll say neither).
2. It doesn’t celebrate the cultural diversity and individuality inherent within our IMGs – which we all can use and learn from.  Actually, Damian Green (former UK’s immigration officer) recently said that ‘to be British is to be part of a ‘tolerant and mutually respectful society’.
3. It might give the impression to others that being ‘British’ implies a sense of a more superior culture, which is clearly not the intention (nor the reality) when trainees are being advised to be more ‘British’.

I think what people mean when they advise their trainees that they need to be ‘more British’ is that they need to develop their linguistic capital in their internal linguistic bank. So let’s go onto define what that exactly means.  Linguistic capital (Bourdieu, 1990) is defined as the mastery of and relation to language. And that doesn’t just mean having a good vocabulary. Other than fluency, we are talking about the expertise and comfort with a language – idioms, turns of phrase and so on.  Trainees can expand their linguistic capital if they submerge themselves in British culture through watching soap operas, widening their social circle of friends and going out with English groups. The idea is that by being immersed in UK idioms, turns of phrase, meta-communication, tone of voice etc., one understands them better and might even start to use them. If IMGs make no attempt to get a grasp of these things, they then remain culturally alien to them. This in turn will affect their learning, growth and thus other people’s (e.g. patients’) faith in them. Investing in linguistic capital is a long term endeavour and that the returns are seldom immediate.

By having good linguistic capital of a culture that is not part of your embodied* cultural capital (i.e. from the country you were brought up in) can give you three good advantages in your host country:

1. It gives you a means of being able to communicate effectively with others (like patients)
2. It gives others some sort of faith, respect and reliance in you.  It’s like presenting yourself and showing that you’ve submerged yourself in your surrounding culture and have acquired a lot from it – and people respect you for that no matter what country you’re in.
3. Linguistic capital thesis states that trainees who possess, or develop linguistic capital, thereby have access to better life chances.
   Remember, linguistic capital can be acquired even by those who do not have ancestral precedents. For example, it is completely possible for a Tamil trainee who still lives with his Tamil speaking parents to acquire linguistic capital that is grounded in English

* Embodied cultural capital = consists of both the consciously acquired and the passively “inherited” properties of one’s self (with “inherit[ance]” here used not in the genetic sense but in the sense of receipt over time, usually from the family through socialisation, of culture and traditions). Cultural capital is not transmissible instantaneously like a gift or bequest; rather, it is acquired over time as it impresses itself upon one’s habitus (character and way of thinking), which in turn becomes more attentive to or primed to receive similar influences. 

In recognition of the issue of differential attainment in MRCGP, Dr Mairi Jamieson and Dr Katie Browne of the West of Scotland Deanery did a piece fo work interviewing IMGs who struggled with the CSA and tried to identify common issues and solutions. This work produced “8 Quick Tips for Trainers with IMGs” (link below). The version of the document linked below is longer due to some discerning reflections from Ian Lamb (SE of Scotland Deanery) but has some incredibly useful insights and is a must read for trainers with IMG GP trainees.

8 TIPS…